What are the associations between the quantity of faculty evaluations and residents' perception of quality feedback?

OBJECTIVES: To determine if there is a correlation between the numbers of evaluations submitted by faculty and the perception of the quality of feedback reported by trainees on a yearly survey. METHOD: 147 ACGME-accredited training programs sponsored by a single medical school were included in the analysis. Eighty-seven programs (49 core residency programs and 38 advanced training programs) with 4 or more trainees received ACGME survey summary data for academic year 2013-2014. Resident ratings of satisfaction with feedback were analyzed against the number of evaluations completed per resident during the same period. R-squared correlation analysis was calculated using a Pearson correlation coefficient. RESULTS: 177,096 evaluations were distributed to the 87 programs, of which 117,452 were completed (66%). On average, faculty submitted 33.9 evaluations per resident. Core residency programs had a greater number of evaluations per resident than fellowship programs (39.2 vs. 27.1, respectively, p = 0.15). The average score for the "satisfied with feedback after assignment" survey questions was 4.2 (range 2.2-5.0). There was no overall correlation between the number of evaluations per resident and the residents' perception of feedback from faculty based on medical, surgical or hospital-based programs. CONCLUSIONS: Resident perception of feedback is not correlated with number of faculty evaluations. An emphasis on faculty summative evaluation of resident performance is important but appears to miss the mark as a replacement for on-going, data-driven, structured resident feedback. Understanding the difference between evaluation and feedback is a global concept that is important for all medical educators and learners.

Implementation of a novel postoperative monitoring system using automated Modified Early Warning Scores (MEWS) incorporating end-tidal capnography.

Modified Early Warning Scores (MEWS) provide real-time vital sign (VS) trending and reduce ICU admissions in post-operative patients. These early warning calculations classically incorporate oxygen saturation, heart rate, respiratory rate, systolic blood pressure, and temperature but have not previously included end-tidal CO2 (EtCO2), more recently identified as an independent predictor of critical illness. These systems may be subject to failure when physiologic data is incorrectly measured, leading to false alarms and increased workload. This study investigates whether the implementation of automated devices that utilize ongoing vital signs monitoring and MEWS calculations, inclusive of a score for end-tidal CO2 (EtCO2), can be feasibly implemented on the general care hospital floor and effectively identify derangements in a post-operative patient's condition while limiting the amount of false alarms that would serve to increase provider workload. From July to November 2014, post-operative patients meeting the inclusion criteria (BMI > 30 kg/m2, history of obstructive sleep apnea, or the use of patient-controlled analgesia (PCA) or epidural narcotics) were monitored using automated devices that record minute-by-minute VS included in classic MEWS calculations as well as EtCO2. Automated messages via pagers were sent to providers for instances when the device measured elevated MEWS, abnormal EtCO2, and oxygen desaturations below 85 %. Data, including alarm and message details from the first 133 patients, were recorded and analyzed. Overall, 3.3 alarms and pages sounded per hour of monitoring. Device-only alarms sounded 2.7 times per hour-21 % were technical alarms. The remaining device-only alarms for concerning VS sounded 2.0/h, 70 % for falsely recorded VS. Pages for abnormal EtCO2 sounded 0.4/h (82 % false recordings) while pages for low blood oxygen saturation sounded 0.1/h (55 % false alarms). 143 times (0.1 pages/h) the devices calculated a MEWS warranting a page (rise in MEWS by 2 or 5 or greater)-62 % were false scores inclusive of falsely recorded VS. An abnormal EtCO2 value resulted in or added to an elevated MEWS score in 29 % of notifications, but 50 % of these included a falsely abnormal EtCO2 value. To date, no adverse events have occurred. There were no statistically significant demographic, post-operative condition, or pre-existing comorbidity differences between patients who had a majority of true alarms from those who had mostly false-positive alarms. Although not statistically significant, the group of patients in whom automated MEWS suggested greater utility included those with a history of hypertension (p = 0.072) and renal disease (p = 0.084). EtCO2 monitoring was more likely to be useful in patients with a history of type 2 diabetes, coronary artery disease, and obstructive sleep apnea (p < 0.05). These patients were also more likely to have been on a PCA post-operatively (p < 0.05). Overall, non-invasive physiologic monitoring incorporating an automated MEWS system, modified to include end-tidal CO2 can be feasibly implemented in a hospital ward. Further study is needed to evaluate its clinical utility, including an end-tidal CO2 score, is feasibly implemented and can be useful in monitoring select post-operative patients for derangements in physiologic metrics. Like any other monitoring system, false alarms may occur at high rates. While further study is needed to determine the additive utility of EtCO2 in MEWS calculations, this study suggests utility of EtCO2 in select post-operative patients.

Association between elevated pre-operative glycosylated hemoglobin and post-operative infections after non-emergent surgery.

BACKGROUND: A chronic state of impaired glucose metabolism affects multiple components of the immune system, possibly leading to an increased incidence of post-operative infections. Such infections increase morbidity, length of stay, and overall cost. This study evaluates the correlation between elevated pre-operative glycosylated hemoglobin (HbA1c) and post-operative infections. STUDY DESIGN: Adult patients undergoing non-emergent procedures across all surgical subspecialties from January 2010 to July 2014 had a preoperative HbA1c measured as part of their routine pre-surgical assessment. 2200 patient charts (1100 < 6.5% HbA1c and1100 ≥ 6.5% HbA1c) were reviewed for evidence of post-operative infection (superficial surgical site infection, deep wound/surgical space abscess, pneumonia, and/or urinary tract infection as defined by Centers for Disease Control criteria) within 30 days of surgery. RESULTS: Patients with HbA1c < 6.5% and those with HbA1c ≥ 6.5% showed no statistically significant difference in overall infection rate (3.8% in the HbA1c < 6.5% group vs. 4.5% in the HbA1c ≥ 6.5% group, p = 0.39). Both linear regression and multivariate analysis did not identify HbA1c as an individual predictor of infection. Elevated HbA1c was, however, predictive of significantly increased risk of post-operative infection when associated with increased age (≥81 years of age) or dirty wounds. CONCLUSIONS: The risk factors of post-operative infection are multiple and likely synergistic. While pre-operative HbA1c level is not independently associated with risk of post-operative infection, there are scenarios and patient subgroups where pre-operative HbA1c is useful in predicting an increased risk of infectious complications in the post-operative period.